Standards › ASF Health Standards v10 › Standard 36
Standard 36
Hospital Emergency Department
Hospital emergency department: triage on arrival, resuscitation readiness, senior clinician responsibility, disposition decisions and patients who leave before assessment..
Each criterion is shown in three settings: Humanitarian settings, Transition and fragile, and Standard. In standard settings, every criterion is Must.
Training colours: red means essential, green recommended, yellow optional. Each course shows its level for each setting: humanitarian, transition and fragile, and standard.
36.1Every Arrival Is Triaged Before WaitingHumanitarian settings: MustTransition and fragile: MustStandard: Must
Every patient arriving at the emergency department is triaged on arrival by a trained clinician, using a recognised triage scale. The triage category decides the maximum time to clinical assessment.
Why it matters. In the emergency department, the patient who looks well may be the one who is most ill. Triage on arrival, by a trained person with a recognised tool, puts the sickest first.
How the surveyor verifies this criterion
Sample. Review arrival and triage records for 30 emergency department attendances across three shifts, including night and weekend.
Immediate fail (any one means the criterion is not met). A patient with chest pain waits three hours in the waiting room without triage.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Checks the criterion at each review | Must |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| HOS-SOP-001 · Emergency triage | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
| HOS-FRM-001 · Triage record and log | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Safety & Emergency Preparedness (H-05) | Manager; Nurse |
References
- WHO (2021). Emergency Triage Assessment and Treatment (ETAT): Manual for Participants. Used for: Triage of children in emergency care (ETAT). Child-specific, not adult triage. https://news.gmj.ge/guideline/emergency-triage-assessment-and-treatment-etat-manual-for-participants/
- WHO (2020). Paediatric emergency triage, assessment and treatment: care of critically-ill children. Used for: Paediatric emergency triage and resuscitation of critically ill children. Child-specific. https://news.gmj.ge/guideline/paediatric-emergency-triage-assessment-and-treatment-care-of-critically-ill-children/
36.2Resuscitation Area Is Always ReadyHumanitarian settings: MustTransition and fragile: MustStandard: Must
A resuscitation area is available at all times. Its equipment and drugs are checked on a documented schedule, and staff on every shift are trained in immediate life support.
Why it matters. A resuscitation area that is not ready when a patient arrives in cardiac arrest costs minutes that cannot be recovered. Equipment and drugs checked on a schedule are ready when needed.
How the surveyor verifies this criterion
Sample. Review resuscitation area checks and drill records for the last 3 months and 10 staff training records.
1. Equipment and drugs are in date and complete at each check.
Method. Check the latest check record against the list of equipment and drugs.
Evidence to show. Resuscitation area readiness register (ED-REG-001).
Pass when. No item is out of date or missing at the last check.
Immediate fail (any one means the criterion is not met). A cardiac arrest with the resuscitation drugs out of date.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Secretary (ISCO 3344) | Keeps the Resuscitation area readiness register | Must |
| Manager (ISCO 1342) | Checks the criterion at each review | Must |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| ED-REG-001 · Resuscitation area readiness register | Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
| ED-POL-002 · Resuscitation area readiness | Chief executive (ISCO 1120) | Governing body members | N/A | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Emergency Medical Equipment & AED Readiness (MED-02) | Manager; Nurse |
References
In process of development. Will be available soon.
36.3A Senior Clinician Is Responsible at All TimesHumanitarian settings: MinimumTransition and fragile: MustStandard: Must
A named senior clinician is responsible for the department at all times. Escalation to specialist services follows a defined pathway with a stated response time.
Why it matters. When something goes wrong in the department, someone senior must be in charge and reachable. Without a named senior clinician, decisions are delayed or made by nobody.
How the surveyor verifies this criterion
Sample. Review the senior clinician duty rota for 30 days, and the escalation log for 10 specialist calls.
1. A named senior clinician is responsible for the department at each time.
Method. Check the rota for a named senior clinician in every period.
Evidence to show. Senior clinician responsibility and specialist escalation (ED-POL-001).
Pass when. No period in the sample has an unnamed senior clinician.
2. Each specialist call follows the defined escalation pathway.
Method. Check each call for the pathway step and the response time.
Evidence to show. Senior clinician on duty record (ED-FRM-001).
Pass when. Every call follows the pathway and has a recorded response.
3. The stated response time for specialist review is met.
Method. Check each call for the time from request to review against the stated time.
Evidence to show. Senior clinician on duty record (ED-FRM-001).
Pass when. Every call meets the stated response time.
Immediate fail (any one means the criterion is not met). No senior clinician on duty overnight and a specialist call goes unanswered.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Maintains the Senior clinician responsibility and specialist escalation | Must |
| Nurse (ISCO 2221) | Completes the Senior clinician on duty record | Must |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| ED-FRM-001 · Senior clinician on duty record | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
| ED-POL-001 · Senior clinician responsibility and specialist escalation | Chief executive (ISCO 1120) | Governing body members | N/A | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Safety & Emergency Preparedness (H-05) | Manager; Nurse |
References
- The on call role of the Emergency Medicine Consultant (Royal College of Emergency Medicine, 2016 (revised February 2016))
36.4Decisions to Admit, Transfer or Discharge Are Recorded and Handed OverHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
The decision to admit, transfer or discharge is recorded with its reasons. Handover to the receiving ward or facility is structured. Interfacility transfers meet the Critical Interfacility Transfer standard (Standard 35).
Why it matters. A decision to admit, transfer or discharge a patient should be recorded with its reasons. A handover that is not made clearly is where the next team misses the problem.
How the surveyor verifies this criterion
Sample. Review admission, transfer and discharge decisions for 30 attendances, and handover records for 15 of them.
1. Each decision to admit, transfer or discharge is recorded with its reason.
Method. Check each attendance for the decision and the reason recorded.
Evidence to show. Disposition decision record (ED-FRM-002).
Pass when. Every sampled decision has a recorded reason.
Immediate fail (any one means the criterion is not met). A patient discharged with no reason recorded and no handover to the GP.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Nurse (ISCO 2221) | Completes the Disposition decision record | Medium |
| Manager (ISCO 1342) | Checks the criterion at each review | Medium |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| ED-FRM-002 · Disposition decision record | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Handover & Communication for ASF Accreditation (MT-04) | Manager; Nurse |
References
- WHO (2020). Medication safety in transitions of care. Used for: Medication safety in patient transfers and discharge, including handover. Medication-specific. https://news.gmj.ge/guideline/medication-safety-in-transitions-of-care/
- World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Geneva: WHO. https://www.who.int/publications-detail-redirect/9789240032705 Used for: https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/
36.5Patients Who Leave Before Assessment Are Recorded and Followed UpHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
Patients who leave before they are assessed or treated are recorded, and the department makes reasonable attempts to follow them up. The rate and reasons are reviewed.
Why it matters. Patients who leave before they are seen may be seriously unwell, and the department must know who they are to follow them up. Recording and following up those patients is part of safe care.
How the surveyor verifies this criterion
Sample. Review the register of patients who left before assessment for the last 6 months, and the follow-up records.
1. Each patient who leaves before assessment is recorded.
Method. Compare the department attendance log with the register for each shift.
Evidence to show. Left-before-assessment register (ED-REG-002).
Pass when. Every departure before assessment is recorded.
2. The department makes reasonable attempts to follow up each recorded patient.
Method. Check each record for the follow-up attempts and their dates.
Evidence to show. Patients who leave before assessment (ED-SOP-003).
Pass when. Every recorded patient has follow-up attempts recorded.
3. The rate and the reasons are reviewed at a set interval.
Method. Check the review entries for the rate and the reasons.
Evidence to show. Left-before-assessment register (ED-REG-002).
Pass when. The rate and reasons are reviewed at the set interval.
Immediate fail (any one means the criterion is not met). Patients who walk out before being seen are not recorded and no one is told.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Secretary (ISCO 3344) | Keeps the Left-before-assessment register | Medium |
| Manager (ISCO 1342) | Maintains the Patients who leave before assessment | Medium |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| ED-SOP-003 · Patients who leave before assessment | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
| ED-REG-002 · Left-before-assessment register | Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Safety & Emergency Preparedness (H-05) | Manager; Nurse |
References
In process of development. Will be available soon.
Who is responsible for Standard 36
Each criterion names the positions responsible for it. Every position links to its own terms of reference.
| Criterion | Responsible | Supports |
|---|---|---|
| 36.1 Every Arrival Is Triaged Before Waiting | Triage nurse Head of emergency department |
Emergency nurse |
| 36.2 Resuscitation Area Is Always Ready | Head of emergency department Emergency nurse |
Emergency physician |
| 36.3 A Senior Clinician Is Responsible at All Times | Emergency physician Head of emergency department |
Consultant physician (internal medicine) |
| 36.4 Decisions to Admit, Transfer or Discharge Are Recorded and Handed Over | Emergency physician Head of emergency department |
Quality manager |
| 36.5 Patients Who Leave Before Assessment Are Recorded and Followed Up | Triage nurse Head of emergency department |
Patient services manager |
Role details: reporting, supervision and training
Training shown is the general recommendation. Role-specific training is set in the next improvement round.
Questions and answers
The criterion text is the authority. These answers summarise it.
Who does Standard 29 apply to?
Hospital emergency departments that receive patients arriving at any time, including those who come without an appointment.
What do the colours mean for this standard?
Red (Must) is required. Green (Medium) is recommended. Yellow (Minimum) is the lowest acceptable level in humanitarian settings. Standard setting is Must on every criterion.
Must every arrival be triaged before waiting?
Yes. Under 36.1 every arrival is triaged before waiting, so a patient with chest pain is not left in the waiting room.
Is the resuscitation area kept ready?
Yes. Under 36.2 the resuscitation area is always ready, with its drugs and equipment available.
Who is responsible for the department at all times?
Under 36.3 a senior clinician is responsible at all times, including overnight.
Are patients who leave before being seen followed up?
Yes. Under 36.5 patients who leave before assessment are recorded and followed up.
Do I have to use the documents on this page?
No. The policies, SOPs, forms and registers are drafts to help you. Adapt them to your department, write your own, or upload your own. What the assessor checks is that the criterion is met and that you can show how.
What does In process of development mean?
That part of the standard is still being prepared. It may be a document, a course, a reference or a role table. It will be added in a later version.
Guidelines for this standard
11 guideline(s) are held in the GMJ Guidelines Library and listed here. Each link opens the full guideline on news.gmj.ge. The complete library, grouped by standard, is at Guidelines.
- Quality Standards for CPR: Acute Care (Resus Council UK)
- The On-Call Role of the Emergency Medicine Consultant (RCEM)
- European Resuscitation Council Guidelines 2021: Basic Life Support (ERC)
- European Resuscitation Council Guidelines 2025: Paediatric Life Support (ERC)
- RCEM Consultant Sign-off standard (Royal College of Emergency Medicine)
- Acute care quality standards for CPR (Resuscitation Council UK)
- Reducing Harm from Ligatures in Mental Health Wards and Wards for People with a Learning Disability (Care Quality Commission)
- Priority assistive products list (2016) (World Health Organization)
- Guidelines for care of critically ill adult patients with COVID-19 in the Americas (Pan American Health Organization)
- Guidelines for Critical Care of Seriously Ill Adult Patients with Coronavirus (COVID-19) in the Americas (Short Version) (Pan American Health Organization)
- Guidelines for Care of Critically Ill Adult Patients with COVID-19 in the Americas, Summary, version 3 (Pan American Health Organization)
Also relevant to this standard:
- Paediatric emergency triage, assessment and treatment: care of critically-ill children (World Health Organization)
- Emergency Triage Assessment and Treatment (ETAT): Manual for Participants (World Health Organization)